Percutaneous Decompression Laminotomy (CPT 0275T)

A safe & durable treatment option for lumbar spinal stenosis

Dr. David Kloth, MD Executive Director Connecticut Pain Society

Disclosures

• No financial or ownership relationship to any company involved (currently or future) with product connected to this procedure • BOD ASIPP • Ex. Dir. CPS • President-Elect NANS • Ex-CAC rep for CT • Assisted in the development of LCD’s on many occasions • NANS representative on the MPW Procedure Overview Lumbar Spinal Stenosis (LSS)

• No pressure on spinal cord • Mobile/flexible • No symptoms (pain, numbness, tingling) Stenosis creates pressure, causing: • Pain, numbness & tingling • Weakness with activity • Pain relieved by flexion (sitting, leaning, bending) • Initial symptom onset generally occurs between 50 – 60 years of age2 • Limited therapeutic options, short of open surgery • Impacts 1.2M1 Patients in U.S. ¹Longitudinal Medicare Database, Quorum Consulting 2Birmeyer NJ, Weinstein JN. Medical versus surgical treatment for low back pain: evidence and clinical practice. Eff Clin Pract. 1999;2:218-227 LSS Symptoms – A Need For Differentiating the Cause

94% of LSS patients3 Neurogenic Claudication Radicular Pain (RP) = (NC) = Thecal sac Nerve root inflammation1 compression / ischemia1,2

Different pathophysiological causes1 require different treatments • Epidural Steroid Injections treat inflammation…NOT ischemia. • Decompression is required to treat thecal sac compression/ischemia.

1Fukusaki, M et al., Symptoms of Spinal Stenosis Do Not Improve After Epidural Steroid Injection. Clinical Journal of Pain: 6/1998;14(2):148-151. 2Porter RW, Spinal stenosis & neurogenic claudication. Spine 1996 Sep 1; 21(17): 2046-52. 3Hall S, Bartleson JD, Onofrio BM, Baker HL, Okazaki H, O’Duffy JD. Lumbar spinal stenosis. Clinical features, diagnostic procedures, and results of surgical treatment in 68 patients. Ann Intern Med 1985;103(2):271-5. LSS Treatment Options

More Invasive Conservative Therapy: Percutaneous Physical Therapy, Decompression Laminotomy/ Exercise Laminotomy Laminectomy

Epidural Interspinous Fusion Steroid Spacers Injections Less Invasive

More Invasive

Percutaneous Decompression Laminotomy achieves the safety profile of conservative treatments with the efficacy of therapeutic treatments. Neurogenic Claudication Treatments: Percutaneous Decompression Laminotomy Candidate

Percutaneous Decompression Laminotomy Candidate:

• Percutaneous DecompressionOpen Surgery Laminotomy is an option when hypertrophic ligamentumCandidate flavum is a predominant factor of LSS • Removal of a small amount of tissue, 1-2 mm, can result in a significant increase in the size of the spinal canal sq.area = 2 휋휋 Percutaneous Decompression Laminotomy: Introduction

• A safe procedure that can help LSS patients stand longer & walk farther with less pain1 • Treats lumbar spinal stenosis (LSS) with neurogenic claudication • Approximately 13,000 patients treated in over 45 states • FDA 510(k) Cleared Devices – “Intended to be used to perform lumbar decompressive procedures for the treatment of various spinal conditions” • CPT Category III: 0275T – Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (e.g., fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar

1Mekhail, Nagy, et al. (2012) Functional and Patient-Reported Outcomes in Symptomatic Lumbar Spinal Stenosis Following Percutaneous Decompression. Pain Practice, 12(6): 417–425. doi: 10.1111/j.1533 -2500.2012.00565.

Percutaneous Decompression Laminotomy: Procedure Description • FDA cleared devices, fluoroscopically guided, safe, outpatient procedure for the treatment of LSS: • Performed through a small portal (5.1 mm) • Requires NO general anesthesia, NO stitches, & NO overnight hospital stay • Limited tissue available to be removed (minimal return of ligament in Tissue Sculpter) • Changes noted in epidurogram (improved / easier flow, thicker / straighter line) • Epidurogram reveals space restoration in debulked / previously stenosed area

Pre-procedure Post-procedure

Percutaneous Decompression Through a 5.1 mm Portal

Debulk the Ligamentum Flavum • Debulking restores space in the spinal canal • Access minimizes tissue disruption • Removal of a small portion of lamina • Removal of excess ligamentum flavum • Leaves anterior ventral fibers of the ligament intact • Supporting structures remain intact (spinous process, facets, & majority of lamina)

Epidurogram

Decompression Procedure Area Percutaneous Decompression Laminotomy & Open Surgery Comparison

Benefits of Percutaneous Laminotomy/ Laminectomy Percutaneous Decompression Decompression (with or without Fusion) Laminotomy Laminotomy

Procedure Setting/ Inpatient: Outpatient: Anesthesia General Anesthesia MAC

2–5 Inches 5.1 Millimeters Incision Length Safe by Design Stitches No Stitches

Days in Hospital 3–5(2) < 1

Complication Rate Low Complication 0.06% Commercial Cases Dural Tear / Blood Loss 23.5%(3) Risk 0% In All Clinical Trials(1) Requiring Transfusion

(4) (1) Responder Rate 60–80% 70 –80% Comparable Efficacy

Average Medicare $20 –80K(4) $4,760(5) Low Cost Reimbursement

1Based on procedure data collected in all clinical trials. 2Deyo, Mizra, Martin, Kreuter, Goodman, Jarvik. Trends, Major Medical Complications, & Charges Associated With Surgery for Lumbar Spinal Stenosis in Older Adults. JAMA, Vol. 303 No. 13. 3Weinstein, et al., for the SPORT Investigators. Surgical vs. Nonsurgical Therapy for LSS. New Engl J Med. 2008;358:794–810. 9.2% dural tear & 14.3% blood loss requiring transfusion reported. 4Weinstein, et al., for the SPORT Investigators. Surgical vs. Nonsurgical Therapy for LSS. New Engl J Med. 2008;358:794–810 52013 Medicare National Average Reimbursement for APC 0208 is $3,760, Physician Fees are Carrier priced and average at $1000 per procedure

Clinical Data Overview Robust Clinical Research

• 16 Published Peer-Reviewed Journal Articles • 11 Clinical Trials, including 542 Patients: – Safety Series – MiDAS I – MiDAS II – MiDAS ECO – Surgery Intolerant – Percutaneous Decompression Laminotomy vs. ESI – Single-Site Series – Cleveland Clinic Study – Single-Site Long Term Series – Independent Case Series with 1 Year Follow-up – Prospective Single-Site Month 6 Report

Peer Reviewed Clinical Literature Demonstrates Safety & Improved Patient Outcomes

Study Author/ Abbreviated # PLD Study Design Summary Outcomes ZCQ Outcomes Post PLD improvement Title Patients -VAS improvement -Symptom (S) -SF 12v2® Physical Component Score (PCS) Milestone -ODI improvement -Function (F) -Others -Satisfaction

Prospective single center RM 7.7 (54% improvement), p<0.0001 ANOVA Endpoints: VAS, Roland Morris (RM), PDI 22.6 (55% improvement), p<0.0001 ANOVA Mekhail et al/ Functional N=40 PDI (Pain Disability Index), Standing ST 56 min (570% improvement), p<0.0001 ANOVA Outcomes Long Term Year 1 Time (ST), Walking Distance (WD) VAS 3.5 (p<0.0001, ANOVA) WD 3710 ft (1510% improvement), p<0.0001 ANOVA S2.35(p<0.0001, t-test) Chopko & Caraway/ MiDAS N=75 Prospective 14 study centers Endpoints VAS 3.6 (p<0.0001, t-test) F1.96(p<0.001, t-test) Phase I Week 6 VAS, ODI, ZCQ. SF-12v2® ODI 17.9 (p<0.0001, t-test) Satisfaction 2.0 PCS = 9.0 (95% CI ± 3.02)

Retrospective Single Center 59% of patients stand longer Lingreen & Grider/ Post-mild N=42 Endpoints: VAS, Standing Time, VAS 3.8 (p<0.05, Mann-Whitney U- 57% of patients walk longer Report Month 1 Walking Time, Satisfaction test) 86% of patients recommended mild to other patients

S 1.16(p<0.001, t-test) Mekhail, et al./mild Long N=58 Prospective, 11 study centers VAS 2.9 (p<0.0001, t-test) F 0.58(p<0.002, t-test) Term Results Year 1 Endpoints: VAS, ODI, ZCQ, SF-12v2 ODI 11.9 (p<0.0001, t-test) Satisfaction 2.2 PCS = 6.1 (95% CI + 2.99)

N=14 Prospective controlled single center VAS 3.9 (p=0.05, ANOVA) ODI 17.2 Chopko/High Risk Patients >Month 8 Endpoints: VAS, ODI (p=0.05, ANOVA)

N=38 Prospective controlled single center VAS 2.9 (p<0.01 Tukey HSD) Brown / RCT ESI vs mild Month 3 Endpoints: VAS, ODI, ZCQ Satisfaction ODI 18.6(p<0.01Tukey HSD) Satisfaction 1.8 S 1.71(p<0.001, t-test) N=27 Prospective controlled single center VAS 5.2 (p<0.0001, t-test) ODI 24.0 F 1.17(p<0.001, t-test) Basu /Single Site Series Month 6 Endpoints: VAS, ODI, ZCQ (p<0.0004,t-test) Satisfaction 1.8 Schomer/mild lumbar N=253 Meta-analysis, 17 study centers VAS 3.5 (p<0.0001, t-test) ODI 17.1 Decompression Month 3 Endpoints: VAS, ODI (p<0.0001 t-test) Wong/ Interlaminar Decompression Long Term N=17 Year Prospective controlled single center VAS 5.4 (95% CI + 1.5) ODI 26.6 Outcomes 1 Endpoints: VAS, ODI (95% CI + 8.8) S 1.2(p<0.0001,t-test) F Deer, et al. / Single Site Long Prospective controlled, single center VAS 2.9 (p<0.0001,ANOVA) ODI 0.8(p<0.0001,t-test) Term mild Results N=35 Year 1 Endpoints: VAS, ODI, ZCQ 17.4(p<0.0001,ANOVA) Satisfaction 1.86

Levy, et al./ Systematic N=109 Year Systematic Review & Meta-analysis VAS 3.9 (95% CI +0.42) ODI 16.0 Review & Meta-Analysis 1 Endpoints: VAS, ODI (95% CI + 3.35) S 0.9(95% CI +0.2) Chopko/ Long-term Results – Prospective 11 study centers Endpoints VAS 2.4 (p<0.0001,ANOVA) ODI 8.6 F 0.4(95% CI +0.2) Two Year Outcomes N=45 Year 2 VAS, ODI, ZCQ. (p<0.0001,ANOVA) Satisfaction 2.2 Note: Clinical relevance was also established in all validated outcomes measures: VAS >2, ODI >6, ZCQ Domains >0.5< Satisfaction <2.5, SF-12v2 PCS > 3 points. Dramatic Functional Improvement at 1 Year1 Cleveland Clinic, Prospective, Single-Center Study

Standing time: 8 to 56 minutes Walking distance: 246' to 3,956’ Improvement allows patients to perform activities To the Around

of daily living: washing dishes, cooking, grocery mailbox the mall shopping Mean Standing Time at Each Mean Walking Distance at Each Follow-up Follow-up

60 Improved 570% 4000 Improved 1,510% 50 3000 40

30 2000

20 N = 34 1000 N = 34 10 Walking Distance Mean Feet Mean Distance Walking Standing Time Mean Minutes Mean Time Standing

0 0 Baseline Month 3 Month 6 Month 9 Month 12 Baseline Month 3 Month 6 Month 9 Month 12 Time Time

Study Background MiDAS I1 • Prospective – Year 1 follow-up • Multi-center – 11 U.S. study centers • Safety – Comprehensive solicited & unsolicited • Patient-Reported Outcomes – VAS: 10-point Visual Analog Scale – ODI: Oswestry Disability Index – SF-12v2®: Health Survey – ZCQ: Zurich Claudication Questionnaire

1Mekhail N, Vallejo R, Coleman MH, Benyamin RM. Long-term results of percutaneous lumbar decompression mild® for spinal stenosis. Pain Pract 2012;12(3):184-193. Year 1 Cohort (N = 58) MiDAS I

Demographics Average Age: 70 Years Length of Stay Female 65.5% Male 34.5% 100 Patients = Less than 24 Hours Patients Treated / Level Total levels 49 treated = 90 33 100% Patients

1 3 4

Total Levels / Patient 27 30 89% of levels Patients Patients were treated bilaterally

1 Patient 1 Level 2 Levels 3 Levels Reduced Pain & Improved Mobility Durable at Year 1

VAS Over Time (Responders1) ODI Over Time (Responders2) Visual Analog Scale (VAS) 1–10 Oswestry Disability Index (ODI) Severely Severe Limited Pain

4 Point 16.6 Point Mean Mean 3 Improvement Improvement Mean ODI ODI Score Mean

No Pain Minimally/ Moderately Limited

Clinically Relevant Clinically Relevant • 79% of all Year 1 Patients were Responders1 • Mean Mobility – 34% Increase • Mean Pain – 53% Reduction Statistically Significant Statistically Significant • p<0.0001, t-test • p<0.0001, t-test

1Responders defined as VAS reductions > 1. 2The published approximate MCID for the ODI version utilized in this study is 6.0 (JM Fritz, JJ Irrgang, Physical Therapy February 2001 vol. 81 no. 2 776–788). 3Year 1 mean ODI improvement of 16.6 points represents 79% of all year 1 patients (responders).

Decompression Required to Treat NC ESI vs. Percutaneous Laminotomy Decompression1

• Prospective, randomized, double-blind, single-center study • 100% of patients had Neurogenic Claudication Symptoms ESI PLD 8 8 * 7 7 6.1 6.3 6 6.2 6 5 5 4 4 3.8 4.1 3 3

Mean VAS Score 2.4 Mean VAS Score 2.5 2 2 1 N=17 1 N=21 0 0 Pre-Tx Week 1 Week 6 Week 12 Pre-Tx Week 1 Week 6 Week 12 Time Time

• Only patients treated with PLD experienced long term pain relief from NC symptoms • After 6 weeks, patients were unblinded & 100% of patients treated with ESI crossed over to PLD – Crossover patients experienced similar improvement as PLD cohort 1Brown, L. A Double-blind, Randomized, Prospective Study of Epidural Steroid Injection vs. The mild Procedure in Patients with Symptomatic Lumbar Spinal Stenosis. Pain Practice, 2012. *n=2 as all other patients had crossed over to mild . These 2 patients crossed over to mild after week 12. Two-Year Outcomes1

• Approx. 75% of 1 Year Patients have reported outcomes at 2 years • Findings are consistent with 1 year outcomes • Published in Clinical Journal of Pain on Feb 26th 2013

Mean Baseline 2 Year Improvement Mean VAS 7.9 4.1 3.8 points (Responders2)

Mean ODI 50.5 38.9 11.6 points (Responders2)

1Chopko, B. Long-term Results of Percutaneous Lumbar Decompression for LSS Two-Year Outcomes. Clin J Pain 2013; DOI. 10.1097/AJP.0b013e31827fb803 [Epub ahead of print]. 2Responders defined as VAS reductions > 1. Response rate 71.1%.

Procedure Safety in Clinical Trials: Percutaneous Decompression Laminotomy vs. Open Surgery

Percutaneous OPEN SURGERY 2 Decompression Laminotomy/Laminectomy

Procedure* with or without Fusion

Number of Patients 3891 394

Dural Tear 0% 9.2%

Blood Transfusion 0% 14.3%

Overall Adverse Events

Intraoperative 0% 9.9%

Postoperative 0% 12.3%

*No major intraoperative or postoperative Percutaneous Decompression Laminotomy device or procedure-related adverse events (blood loss requiring transfusion, dural tear, hematoma, nerve root damage) reported in any clinical studies. A total of 7 adverse events have been reported in over 13,000 commercial cases, a rate of 0.06%.

11. MiDAS I (78 Patients) 2. Single-Site Series (42 Patients) 3. mild vs. ESI (38 Patients) 4. Safety Series (90 Patients) 5. Single-Site Long Term Series (46 Patients) 6. MiDAS II (55 Patients) 7. Cleveland Clinic Study (40 Patients) (see bibliography) 2Weinstein, et al., for the SPORT Investigators. Surgical vs. Nonsurgical Therapy for LSS. New Engl J Med. 2008;358:794–810. Health Care System Burden Health Care System Impact

Percutaneous Traditional Open Decompression Procedure vs. Decompression Surgery Hospital Stay <1 Day1 3-5 Days4 <0.06% Commercial2 Complication Rate (13,000 cases in 45 states) 23.5%5 – Dural Tear / Blood Loss Requiring Transfusion 0% all clinical trials1 Anesthesia MAC/Light General Average Medicare $4,7606 $23,7244 Reimbursement

Lack of overnight hospital stay & no general anesthesia equates to much lower hospital charges. Medicare cost savings= $18,964 or 80% 1 Based on mild® procedure data collected in all clinical trials. No major intraoperative or postoperative mild Device or procedure-related adverse events (blood loss requiring transfusion, dural tear, hematoma, nerve root damage) reported in any clinical studies. 2 Based on mild® procedure data collected in all reported commercial cases. 3 Based on mild® procedure data collected in all clinical trials. 4 Deyo, Mizra, Martin, Kreuter, Goodman, Jarvik. Trends, Major Medical Complications, & Charges Associated With Surgery for Lumbar Spinal Stenosis in Older Adults. JAMA, Vol. 303 No. 13. 5Weinstein, et al., for the SPORT Investigators. Surgical vs. Nonsurgical Therapy for LSS. New Engl J Med. 2008;358:794–810. 62013 Medicare National Average Reimbursement for APC 0208 is $3,760, Physician Fees are Carrier priced and average at $1000 per procedure The Case for Coverage Percutaneous Decompression Laminotomy fulfills Medicare Coverage Criteria

• Percutaneous Decompression Laminotomy satisfies Medically Necessary & Reasonable criteria as defined in the Medicare Program Integrity Manual – FDA Cleared for “performing lumbar decompressive procedures” – 13,000 patients treated in 45 States – Robust clinical studies demonstrating efficacy & safety – Positive Medicare Coverage established in 23 states – “Reasonable & Necessary” affirmed by 132 ALJ decisions • Medically necessary services must have been established as safe and effective and must be: – Consistent with the symptoms or diagnosis of the illness or injury under treatment – Necessary and consistent with generally accepted professional medical standards (e.g., not experimental or investigational) – Furnished by qualified personnel – At least as beneficial as an existing and available medically appropriate alternative The Case for Coverage

• Health Care System Burden Minimization: – Outpatient/ASC (No overnight hospital stay required) – No general anesthesia required – 80% cost savings over reported simple open surgery decompression procedures – Unique code designed to track procedure results • Proven Safety & Efficacy: – 11 Independent Clinical Trials & 16 Peer Reviewed Publications – Body of evidence contains Levels I, II and III clinical trial evidence – Statistically significant & clinically relevant pain & mobility improvement in all studies – Per SORT & other systems as presented in AHRQ = Grade A Recommendation – Extremely low complication rate = low risk (0% in clinical trials, <0.06% in commercial cases) – CMS included procedure on the ASC approved procedure list for 2013 based on safety profile

Current Medicare (MAC) Coverage: Percutaneous Decompression Laminotomy, CPT 0275T

Total number of states & MACs (Medicare Administrative Contractors) with positive coverage: MAC States Covered Total States CGS (Cigna Government KY, OH 2 Services) Palmetto NC, SC, VA, VW 4 Palmetto CA, NV, HI 3 NHIC (National Heritage Ins MA, RI, NH, VT, ME 5 Co) WPS (Wisconsin Physician IA, KS, NE, IA 4 Services) WPS (Wisconsin Physician MI, IN 2 Services) WPS (Wisconsin Physician MN, WI, IL 3 Services)

Total 23 Published Coverage Criteria

Coverage criteria published by WPS (Wisconsin Physician Services): • “Lumbar canal stenosis is a common cause of chronic LBP and leg pain. Minimally invasive lumbar decompression (MILD) is a new procedure for pain relief from symptomatic central lumbar canal stenosis. It entails limited percutaneous laminotomy and thinning of the ligamentum flavum in order to increase the critical diameter of the stenosed spinal canal. WPS Medicare has concluded that clinical literature supports that the MILD procedure, when medically indicated, appears to be a safe and a likely effective option for treatment of neurogenic claudication in patients who have failed conservative therapy and have ligamentum flavum hypertrophy as the primary distinguishing component of the stenosis.”

Thank You Strength of Evidence: Evaluation of the Percutaneous Decompression Laminotomy Body of Evidence

Key elements in systems used to assess strength of evidence: • Quality: Study design and minimization of opportunity for bias • Quantity: Total number of studies, sample size or power, magnitude of treatment effect/mean change from baseline • Consistency: Similar findings between similar and different study designs or populations on a given topic/reproducibility of the results across studies

Systems useful to assess strength of body of evidence: • SORT1 (Strength of Recommendation Taxonomy – Journal of Family Practice,) assesses strength as Grade A, B, or C • Multiple systems presented in Agency for Health and Research Quality2 (AHRQ Publication 02-E016) such as CEBM (Center for Evidence Based Medicine) • Evaluating the body of evidence for Percutaneous Decompression Laminotomy using SORT or CEBM type systems: – Grade A recommendation

1Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): A patient-centered approach to grading evidence in the medical literature. J Fam Pract 2004;53(2):111-117. 2West S, King V, Carey TS, et al. Systems to rate the strength of scientific evidence. Agency for Healthcare Research and Quality (AHRQ) Publication No. 02-E016. Evid Rep Technol Assess 2002;47:1-204.